Power of Prediction: "Of each particular thing, ask: 'What is it in itself, in its own construction?'" -Marcus Aurelius


 
 

Paul A. Werfel, NREMT-P | From the June 2008 Issue | Monday, September 8, 2008


Everywhere we look, there are patterns. Most city streets are set up as grids, bridges are typically constructed using distinctive arches, and when the noontime sky darkens (such as in the Northeast today) bad weather soon follows.

But when it comes to our patients, can we make reliable predictions based on patterns? Or do we need to experience these patterns to truly understand them? Let's look at this month's case to find out.

Case presentation

You're on a paramedic first-responder vehicle for a department for which you work part time, and joining you today is a paramedic student, Chris. The day starts out quietly enough. You check your vehicle and equipment. You visit the other stations and check the ambulances, ensuring the equipment is on board to handle any and all major incidents.

You also review with your student the approach you will take toward any patients. You know that classes often don't do a good job teaching students to play nicely with a group, instead teaching them to be "team leaders," so you're talking it over with ChrisƒWho's the alpha dog when three alpha dogs are on the scene?

While you're talking, the activation tones sound, and the dispatcher announces an "EMS alarm"ƒelderly female unconscious at the "J wing" of the Gardiner Assisted Living Center, Rt. 743 and Atria Lane. Time out is 10:03 p.m. As you tell the dispatcher you're responding, your mind reviews the possibilities.

Gardiner is one of several assisted-living or nursing homes that have opened in the district during the past several years. The dispatcher tells you that Jason, an EMT-I first responder and volunteer member of the department, is responding to the scene from his home. You know he lives fairly close.

You receive additional information that the patient is in the facility's cafeteria. At the same time, Jason tells the dispatcher he's on scene.

As your SUV makes the turn onto Rt. 743, Jason is on the air, stating he has an elderly female in "cardiac arrest, please tell the medic to step on it!" You increase your speed (to a safe and legal level) and tell the dispatcher you're two minutes out.

You and Chris exit the truck and head to the cafeteria to find Jason talking to an elderly female lying on the ground. She's responding appropriately, and Jason tells you he found her in cardiorespiratory arrest at a table with four other older women. He says he pulled her to the floor and bagged her twice. She then started to breathe again and had a pulse.

You find that the patient's airway is clear and ask Chris to obtain vitals. BP 148/90, pulse of 100 and regular and strong, respirations of 12 with clear lung sounds. Chris begins to secure the IV line, and you check the 12-lead ECG, which demonstrates sinus rhythm at 100.

You haven't seen post-cardiac arrests come back with such good vital signs, much less be alert and oriented afterward, so you ask some questions of the ladies sitting with the patient. You discover they're all close friends and intimately familiar with each other's medical history.

They state the patient has epilepsy but no heart or lung problems and has never had a stroke. You ask, "When she has her epilepsy, does she fall to the ground and shake, or does she just seem to slump over and black out?" The ladies all answer that she just slumps to the side, like she did earlier.

Your patient suffers from petit mal seizures. This condition presents as self-limiting periods of blinking, tremors or pauses in speech. The eyes may close, and it seems like the film breaks during a movie. This is what Jason witnessed, not a cardiac arrest. All in all, a good outcome. No cardiac arrest, up triaging of a potentially serious case and another EMS secret revealed to the student and Jason.

Just to be safe, you take her blood glucose (118) and obtain a 12-lead ECG (normal) and transport to the hospital, monitoring her for the 10-minute ride. Another life saved.

Discussion

Much of what we do, at all levels, is recognize patterns. As an EMS teacher, it's a primary concern that my students learn to "pattern recognize." However, they must keep an open mind while doing so. This is the process of experiential learning, and it's invaluable.

This process reminds me of a Zen Buddhism tale I read in Deep Survival: Who Lives, Who Dies & Why, about a young man who passionately wants to become a master swordsman. The man seeks out a Kundo master and begs to be taught, but the master puts him to work in the garden instead. The student isn't happy but obediently works the garden.

Every time the student isn't looking, the master sneaks up behind him and whacks him with a stick. Although terribly frustrated, the student stays, and this pattern continues for years. No matter what the students tries, he can't seem to sense when the master is behind him. As a result, he's constantly covered with welts and bruises.

One day, the young man is tending to the garden when the master sneaks up behind him and swings, but the student ducks and the master misses. The student is overjoyed. He grabs the master and shouts, "Now will you teach me swordsmanship?"

"Now, you don't need swordsmanship," the master replies.

Paul Werfel, NREMT-P,is the paramedic program director for the University Medical Center at State University of New York, Stony Brook. Contact him via e-mail atpaul.werfel@stonybrook.edu.




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Related Topics: Patient Care, Cardiac and Circulation, Airway and Respiratory, Patient Management, Training, Jems Case of the Month

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